Referral Form
Name:
*
First Name
Last Name
Phone Number:
*
Email:
*
example@example.com
Date of Birth:
*
-
Month
-
Day
Year
Date
Gender:
Parent/Guardian Name & Relationship to client, if client is a minor:
Form of Payment:
*
Private Pay
Private Insurance
Medicaid
Insurance Provider:
*
Please tell us briefly why you are seeking therapy services at this time:
*
What service(s) are you interested in (please check all that apply)?:
*
Outpatient Therapy
Ketamine Assisted Psychotherapy
Ketamine Integration
Reiki
Requesting services with:
*
Heather Pickart, LISW
Julie Mertz, LMFT
No preference
Are you wanting to meet:
*
In person
Telehealth
What is your availability (please check all that apply)?:
*
Morning (before noon)
Afternoon (12pm-5pm)
Evening (after 5pm)
Are you currently working with a psychiatrist or medication management provider?:
*
Yes
No
Submit
Should be Empty: